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Providers should center their postpartum patients’ values and preferences when offering guidance and care regarding breastfeeding and hormonal contraception, according to a recent paper from faculty at the UNC Department of Obstetrics and Gynecology.

Amy Bryant, MD, MSCR, associate professor in the Division of Family Planning at UNC OB-GYN, is the lead author of the commentary, “Hormonal contraception, breastfeeding and bedside advocacy: the case for patient-centered care,” which appeared earlier this year in Contraception. Alison Stuebe, MD, MSC, associate professor in the Division of Maternal-Fetal Medicine at UNC OB-GYN and Medical Director of Lactation Services at UNC Health Care, is a co-author on the paper.

In the paper, Bryant and her team describe an instance where a 15-year-old patient who had recently delivered an extremely preterm child declined a long-acting reversable contraceptive (LARC) implant after a lactation consultant noted that it might impact her milk supply. Existing research doesn’t show an adverse effect of hormonal contraception on milk production, but those studies were mostly among healthy mothers of term babies. Both preventing unintended pregnancy and increasing breastfeeding rates are important public health goals, and the paper’s authors argue that the patient’s values on those topics should be explored when making decisions that could impact either.

This is called ‘bedside advocacy,’ says Bryant, where different providers with different health priorities offer divergent interpretations of the data at the patient’s bedside, influencing the outcome. In this case, the patient’s needs are complex, as the patient is at a high-risk for repeat pregnancy, and breastmilk is critically important for her preterm baby’s health. The paper provides a list of questions about birth spacing, breastfeeding, contraception, sexual activity and more that providers can use to counsel patients toward a shared decision.

“Though it is certainly plausible, the preponderance of the evidence shows that hormonal contraception does not reduce milk production or breastfeeding. But it is important to use shared-decision making tools and interviewing techniques when counseling a postpartum patient on contraception,” says Bryant. “Patients may value the benefits of breastfeeding or
contraception differently than their care providers. Working together is the best way to find an option that most fits the patient’s individual needs.”

Many women in the postpartum period have concerns about the adverse impact of hormonal contraception on breast milk production, and providers often interpret the impact on contraception on breastfeeding in a way that supports their own personal priorities. In clinical situations, women may feel led to make choices that don’t reflect their own needs, such as the need to prevent pregnancy or the desire to prioritize breastfeeding over contraception.

“It is anecdotal, but some women do report that they experience changes in milk production with progesterone-containing contraception,” says Stuebe. “For this reason, we do need to make sure we discuss both hormonal and non-hormonal intrauterine devices, and as well as implants, with all of our patients.”

Social and racial injustices further complicate bedside advocacy as conversations regarding reproduction. The history of the forced sterilization of women of color throughout the 20th century may have deeper implications regarding approaches to breastfeeding and contraception. The authors recommend that health care providers make a conscious effort to avoid perpetuating the systematic devaluing of reproduction of poor women and women of color through coercive contraception counseling, whether that coercion is done consciously or unconsciously.

Stephanie Devane-Johnson, PhD, CNM, associate professor at Vanderbilt School of Nursing and former faculty member at UNC OB-GYN is a co-author on the paper. She says breastfeeding disparities still remain in the African American community.

“However, the barriers are being addressed by increasing the number of peer counselors and lactation consultants of color and illuminating cultural and historical aspects that contribute to the low number. The disparity is multi-dimensional and must be addressed from many directions.”

The best way forward in postpartum contraception counseling is a patient-centered approach to care where the provider, knowledgeable about postpartum care, and the patient, the expert on her own body and her own life goals, come up with a plan together.

“Counseling on contraception and breastfeeding offers a critical opportunity for providing care that is respectful of and responsive to patients’ individual needs, preferences and values,” says Bryant. “We should use these opportunities to make sure that each patient’s individual situation is recognized and treated with respect.”

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